j. perinat. med. maternal perception of fetal movements

Schmidt et al., Perception of fetal movements 313

Original articles

J. Perinat. Med.12 (1984 )313

Maternal perception of fetal movements and real-time ultrasoundfindings

W. Schmidt, L Cseh*, K. Kara**, F. Kubli

Department of Obstetrics and Gynecology, University of Heidelberg,F.R.Germany

* Postgraduate Medical School, Department of Obstetrics and GynecologyBudapest (Head: Prof. Dr. I. Gati), Hungary

** Department of Obstetrics and Gynecology, University of Tokyo(Head: Prof. Dr. S. Sakamoto), Japan

Introduction

The registration of fetal movements by the motheris traditionally considered to be a useful methodof monitoring the fetal well-being [8, 17]. Over thepast decade the interest in recording fetal activityhas increased both by semiquantitative standard-ization of maternal perception and by the develop-ment and application of new technologies [2, 7,15].In the past, the monitoring of fetal motor activityhas been based on indirect methods of detection.These methods have included maternal perception[12], electromagnetic pressure sensors [2], observerpalpation, strain gauge devices [23], tocodyno-metric transducers [21] and piezo-electric crystals[18].Simultaneous monitoring of fetal movements withmaternal perception and ultrasound was done byGETTINGER et al. for the first time [3] using onereal-time ultrasound transducer. This was laterrepeated by HERTOGS et al. [4] applying twotransducers simultaneously. Beginning in 1981 aprospective study was started in our departmentwith simultaneous assessment of fetal motoractivity by real-time ultrasound and maternalperception. A comparison of these two methodsis described below.

* *# Supported by A. von Humboldt-Stiftung

Materials and methods

Fifty patients in the second half of pregnancywere monitored simultaneously with two ultra-sound instruments. Thirty-three patients showedan uncomplicated course of pregnancy, sevensuffered from threatened premature labor. Thestudy included also one patient with toxemia, onepatient with diabetes mellitus, and eight patientswith growth retarded fetuses below the 10thpercentile according to THOMSON et al., 1968[20]. The age of the patients ranged from 18 to39 years. All patients except nine had a mealbefore the examination. Thirty-nine examinationswere done between 8 and 10 a.m. and 11 examina-tions between 4 and 6 p.m. The examinationswere performed in a semi-recumbent positiontilted to the left with a pillow to prevent vena cavaocclusion syndrome. The design of monitoring thetotal fetal motor activity is shown in Fig. 1. Thisinvolved the use of two ultrasound instruments:i.e., M 2130 ADR, 3.5 MHz and Superscan 50ROCHE-bioelectronics, 2.8 MHz. Monitoring alsoincluded registration of trunk movements, thoracicmovements (breathing movements), movements ofthe upper and lower extremities, fetal heart fre-quency, and tocography. One ultrasound trans-ducer with 10.7cm active length was placed torecord cross-sections of the lower thoracic region,the arms, and the trunk. Another transducer with11.7 cm length likewise was placed to record thelegs.

© by Walter de Gruyter & Co. Berlin · New York

314 Schmidt et al., Perception of fetal movements

MATERNAL PERCEPTION ιΟΟ

Fig. 1. Scheme of monitoring "total" fetal body move-ments with two ultrasound transducers and maternalperception of fetal movements simultaneously. In addi-tion to this FHR and also tocographic findings werestored synchronously on a magnetic tape recorder.

Cases with fetal hiccoughs were excluded from thestudy. Movements were recorded as a single move-ment when the interval between two movementswas less than two seconds. The beginning and theend of each fetal movement was marked by thepatients and by the observers — "breathing" move-ments, body movements, movements of the upperand lower extremities were stored synchronouslybut separately on magnetic tape — using a pushbutton system. Fetal movements were defined as"gross" movements when movements of the upperand/or lower limbs occurred simultaneously withbody movements.

Results

The distribution of all 50 examined patientsaccording to gestational age is shown in Tab. I. Weobserved 31 nulliparous and 19 multiparouswomen. In 23 cases the placental location wasposterior, in 27 cases mainly anterior of the uterus.The mean weight of all examined patient was65 kg (50.5 kg to 93.4kg). In a total registrationtime of 18 hours 29 minutes 417 fetal body move-ments and 1,920 movements of the extremitieswere detected by ultrasound. A total of 2,337movements (i.e. combined or isolated movementsof fetal body and/or the extremities excluding

Tab. I. Number of examined patients according to gesta-tional age (weeks).

;j .

Gestational age < 31 32-34 35-37 38-40(weeks)Number of patients 6 10 22 12

fetal "breathing") could be detected sonographic-ally. Most of the movements of the extremities(1515/1920 = 79%) were part of "gross" move-ments of the fetuses. Later analysis of magnetictape recordings showed altogether 822 discernablesingle movements.A mean of 17.1 mvts/22min, could be observedwith a range of 0 to 60 mvts. There was one casewith an intrauterine growth retarded fetus inwhich no fetal movement activity could be detectedduring the whole examination time. But there wasalso one unaffected fetus which showed no move-ments at all. Tab. II shows the relationship of fetaltrunk movements to movements of the extremities.In 86 % of all body movements the "gross" bodymovements were registered sonographically.Isolated movements of the extremities occurred inonly 14% (upper extremities) and in 7% (lowerextremities) respectively. Of all discernable singlemovements monitored by ultrasound the mothersregistered 37%. A maximum maternal perceptionof 63 % was noted in the group of fetal "gross"

Tab. II. Incidence of body movements, "gross" move-ments (i.e. movements of fetal body and simultaneousmovements of the extremities) and movements of theupper and lower extremities detected by ultrasoundexamination.

All body movements observedBody movements combined withmovements of the extremities, i.e.the "gross" movementsBody movements withoutmovements of the extremities

Number417

361

56

100%

86%

14%

All movements of the extremitiesobserved 1920 100%Movements of the upper and/orlower extremities with bodymovements synchronously 1515 7 9 %Upper extremities only 270 14 %Lower extremities only 135 7 %

J. Perinat. Med. 12 (1984)


Tab. III. Maternal perception of different fetal singlemovements ("gross" movements, trunk movements andisolated movements of the extremities).

maternal perceptionfetal body movements

Perception of all single movements(excluding "breathing")

Perception of "gross" movementsPerception of isolated trunkmovementsPerception of movements of the upperextremitiesPerception of movements of the lowerextremities

305/822

226/361

18/56

40/270

21/135

37%

63%

32%

15%

16%

65 _

60 -

55 -

movements. Fetal body movements without simul-taneous movements of the extremities were felt bythe mothers in 32% and isolated movements of theextremities were felt in only 15 % (cf. Tab. III).The push button system was used by the mothers764 times (the pusti-button systems were usedseveral times by the mothers during fetal "gross"body movements), indicating correct perceptionof fetal movements in 536/764 (70%) whereas thepush button system was used without sonographic-ally detectable movements of the fetus in 228/764(30%) instances (cf. also Tab. IV). Most instancesof correct maternal perception occurred withsynchronous fetal body movements (81%). Ofthose patients with falsely registered movements,

Tab. IV. Correct positive and false positive maternal per-ception of fetal movements.

Push-botton system used by themother (including severalperceptions during "gross"movements)Correct maternal perceptionFalse positive maternal perception

67%(η·19)

Γ56%(η-20)

I<33

I33- 36 >36 weeks

764536228

100%70%30%

Correct positive perception inrelation to body movements with/orwithout limb movements 435/536 81%Isolated movements of the upperand/or lower limbs 101/536 19 %

False positive maternal perceptionin relation to contractions 42/228 18 %Fetal "breathing" 80/228 35 %Without detectable reason 106/228 47 %

Fig. 2. Maternal perception of fetal body movements andgestational age (p < 0.01 between both groups < 33 weeksand > 36 weeks).

no reason could be ascertained in 47%. Fetal"breathing" was present in 35% and contrac-tions demonstrated by tocography was noted inthe remaining 18 %. With increasing gestational agethe mothers showed a more accurate perception offetal movements (cf. Fig. 2) (p < 0.01 between< 33 weeks and > 37 weeks, chi2-test). Accordingto parity, multiparous women registered fetalbody movements in 73 % whereas nulliparouswomen detected only 51% of fetal body move-ments (p< 0.001, chi2-test). No difference ofmaternal perception of fetal movements could beshown with reference to placental location orobesity of the mother.

Discussion

The usefulness of maternal perception of dailyfetal motor activity has been proposed by manyauthors [1, 5, 10, 13, 16]. Other methods ofrecording fetal movements have also been de-scribed [6, 11, 14, 15, 19, 23]. The difficulties of



retrospective evaluation of fetal movements bycardiotocography have been pointed out [9]. Itwas reported that 90% of fetal movements wereoverlooked. Another group [15] using an electro-magnetic device stated that on the average, patientsfelt 87% of the observed movements. With twohighly sensitive piezo-electric sensors they wereable to improve the detection rate of fetal move-ment to 90.4% [18].The subjective maternal perception was comparedwith the real-time ultrasound assessment of fetalmovements by another study group [3]. There wasa significant positive correlation between the num-ber of movements recorded by both methods. Oneproblem with this study was that the 95% con-fidence limits were rather wide. Additionally, amean of 57% of fetal movements detected byultrasound were not perceived by the respectivemothers. HERTOGS et al. (1979) [4] were the firstto assess "total" fetal motor activity simultane-ously with two ultrasound transducers. They com-pared their findings to maternal perception. Intheir study the patients perceived a mean of 33 %of all movements detected by real-time ultrasound.They showed that the probability of a movementbeing perceived increased with the number of fetalparts moved. A maternal perception of only 8 %for movements of an isolated fetal part to a highof 63 % for major movements; i.e., movements ofall four fetal extremities was demonstrated. Theyfound no statistically significant differences inmaternal perception with regard to parity, gesta-tional age, placental location and obesity of themother.In our study a modified examination procedurecomparable to that of HERTOGS et al. (1979) [4]was used first. "Total" fetal motor activity wasregistered by two observers and maternal percep-tion of fetal movements was stored simultane-ously. Of all movements detected by ultrasoundthe mothers perceived a mean of 37%. "Gross"body movements were perceived in 71% whereasisolated movements of the trunk and isolatedmovements of the extremities were perceived inonly 32% and 15% respectively. Thirty percent

of the maternally perceived movements were with-out a sonographically detectable fetal movement.

jln 18% of false positive maternal assessments, auterine contraction was registered on the toco-graphic chart. Another 35% demonstrated fetal"breathing" activity and in 47% the mother usedthe push button without a detectable reason.To a great extent our findings are in agreementwith the results of HERTOGS et al. [4]. They arecontradictive to other data [13] where only oneultrasound transducer was utilized. This may have

ι been due to an unknown number of fetal move-jments missed by the observer himself. The sameauthor [13] found no false positive reporting offetal movements by the mothers. This, however,we could not confirm. In our study, besides mater-nal perception, real-time ultrasqnography andtocodynometry were employed to monitor syn-chronously all combined or isolated fetal move-ments, "breathing" movements and uterine con-tractions. It is our opinion that the use of theseadditional techniques helps to assess maternalperception more reliably and objectively.In contrast to HERTOGS et al. (1979) [4] wefound a higher rate of perception of fetal move-ments in multiparous patients than in nulliparas(p < 0.01). A more accurate perception of fetalbody movements was also observed with increasinggestational age (p < 0.01). Maternal sensitivity tofetal movements did not seem to depend on mater-nal age, placental location or obesity. The resultsof this study suggest that most mothers are reli-ably reporting "gross" fetal body movementswhereas isolated movements of the extremities orthe fetal trunk might not be felt by the mothers.Furthermore, fetal "breathing", BRAXTON-HlCKScontractions and perhaps passive fetal displace-ment may lead to false registration of fetal move-ments by the mother. Psychological as well asphysical factors may also increase maternal sensi-tivity to fetal movements [22]. These factors alongwith the relatively high rate of false positiveperceptions should be considered if the mother'srecord of daily fetal movements is used as amethod of fetal monitoring.



Summary

Two real-time ultrasound instruments were used simulta-neously for comprehensive recording of "total" fetalmotor activity in 50 patients in the second half of preg-nancy. Synchronously, cardiotocographic findings andmaternal perception of fetal movements were stored onmagnetic tape. In most cases fetal "gross*' movementswere perceived by the mothers (mean: 63%). Isolatedmovements of fetal extremities were reported by themother in only about 15 % of all cases. Mothers registereda total of all movements in 37%. We found a statisticallysignificant difference in the percentage of perceived fetalmovements with regard to parity (p < 0.001) and with

regard to gestational age (p < 0.01). With multiparity oran increasing gestational age the body movements of thefetuses were felt more accurately by the mothers. In 30%of all cases the mothers perceived movements withoutsonographic confirmation.The findings of this study suggest that maternal percep-tion of major fetal body movements is accurate in themajority of cases. However, the relatively high rate offalse positive maternal perception should be taken intoconsideration if the maternal record of daily fetal move-ments is to be used for fetal monitoring.

movements with regard to parity (p < 0.001) and withKeywords: Fetal monitoring, fetal motor activity, maternal perception, real-time ultrasound.

Zusammenfassung

Mütterliche Perception der fetalen Bewegungen und Real-Time-Ultraschall-ErgebnisseDie totale fetale Bewegungsaktivität wurde bei 50 Mütternin der zweiten Schwangerschaftshälfte durch die simul-tane Untersuchung mit zwei Ultraschallgeräten erfaßt.Zeitsynchron hierzu wurde ein Kardiotokogramm abge-leitet und die mütterliche Perzeption fetaler Bewegun-gen auf Magnetband gespeichert. In der Vielzahl derFälle wurden sog. „Gross"-Körperbewegungen durch dieMütter selbst festgestellt (durchschnittlich: 63%). Dage-gen wurden isolierte Extremitätenbewegungen nur in 15 %von den Müttern registriert. Von allen sonographischnachweisbaren Bewegungen fühlten die Mütter nur 37%.Statistisch signifikante Unterschiede konnten zwischen

nulli- und multiparen Frauen festgestellt werden(p < 0.001). Ebenso wurden Fetalbewegungen gegenEnde der Schwangerschaft signifikant deutlicher wahr-genommen als zu Beginn des letzten Schwangerschafts-drittels (p < 0.01). In 30% betätigten die Mütter dasKnopf-Druck-System ohne den sonographischen Nach-weis einer fetalen Bewegung.Diese Ergebnisse zeigen, das sog. fetale Ganzkörper-bewegungen zumeist durch die Mütter selbst erkanntwerden können. Allerdings sollte die relativ hohe Ratefalsch-positiver mütterlicher Registrierungen immer mitberücksichtigt werden falls zur fetalen Zustandsdiagnostikdie Registrierung fetaler Bewegungen durch die Mütterverwendet wird.

Schlüsselwörter: Fetale Bewegungsaktivität, fetale Zustandsdiagnostik, mütterliche Perzeption, Real-Time-Ultraschall.

Resume

Perception maternelle des mouvements foetaux et donneesechographiques en temps reelDeux appareils d'echographie en temps reel ont eteutilises simultanement afin d'enregistrer la totalite deFactivite foetale motrice chez 50 patientes au cours de laseconde moitie de la grossesse. On a enregistre simultane-ment sur bände magnetique les donnees caidiotocogra-phiques et la perception maternelle des mouvementsfoetaux. Dans la plupart des cas, les mouvements globauxdu foetus sont pergus par les meres (en moyenne: 63%).Les meres ne signalent les mouvements isoles des extremi-tes du foetus que dans 15 % des cas. Les meres pergoivent37 % de la totalite des mouvements foetaux seulement. Ona trouve des differences statistiques significatives entre les

pourcentages des mouvements foetaux pergus en ce quiconcerne la parite (p 0,001) et Tage gestationnel (p 0,01).En cas de multiparite ou ä mesure que Tage gestationnelprogresse, les mouvements foetaux furent perqus plusdistinctement par les meres. Dans 30 % des cas, les meresperqoivent des mouvements sans qu'il y ait confirmationechographique.Les donnees de cette etude suggerent que la perceptionmaternelle des mouvements importants du corps du foetusest appropriee dans la majorite des cas. Neanmoins, ondevrait prendre en compte le pourcentage relativementeleve de faux positifs dans la perception maternellelorsque utilise Fenregistrement quotidien par la meredes mouvements foetaux pour la surveillance du foetus.

Mots-cles: Activite motrice du foetus, echographie en temps reel, monitoring foetal, perception maternelle.

Bibliography

[1] BIRGER, M., R. HOMBURG, V. INSLER: Clinicalevaluation of fetal movements. Int. J. Gynecol.Obstet. 18(1980)377

[2] BODDY, K., C. MANTELL: Observation of fetalbreathing movements transmitted through maternalabdominal wall. Lancet I (1972) 1219

[3] GETTINGER, A., A. B. ROBERTS, S. CAMPBELL:Comparison between subjective and ultrasoundassessments of fetal movement. Br. Med. J. 2 (1978)88

[4] HERTOGS, K., A. B. ROBERTS, D. COOPER et al:Maternal perception of fetal motor activity. BrMed. 1.2(1979)1183



[5] HOMBURG, R., A. MATZKEL, M. BIRGER etal:Management of patients with a live fetus and cessa-tion of fetal movements. Br. J. Obstet. Gynaecol. 87(1980)804

[6] MANNING, F. A., L. D. PLATT et al.: Antepartumfetal evaluation: Development of a fetal biophysicalprofile. Am. J. Obstet. Gynecol. 136 (1980) 787

[7] MATHEWS, D. D.: Measuring placental function.Br.Med. J.I (1972) 439

[8] NELDAM, S.: Fetal movements as an indicator offetal well-being. Lancet I (1980) 1222

[9] NELDAM, S., P. JESSEN: Fetal movements regis-tered by the pregnant women correlated to retro-spective estimations of fetal movements from cardio-tocographic tracings. Am. J. Obstet. Gynecol. 136(1980) 1051

[10] PAYNE, P. ., . . GORDON et al.: Fetal deathwithout preceding fetal movement. N. Engl. J. Med.303(1980)1419

[11] PATRICK, J., K. CAMPBELL, L. CARMICHAELet al.: Patterns of human breathing during the last10 weeks of pregnancy. Obstet. Gynecol. 56 (1980)24

[12] PEARSON, G. F., J. B. WEAVER: Fetal activity andfetal wellbeing: An evaluation. Br. Med. J. (1976)1305

[13] RAYBURN, W. F.: Clinical significance of percepti-ble fetal motion. Am. J. Obstet. Gynecol. 138 (1980)210

[14] ROBERTS, A. B., D. GRIFFIN, R. MOONEY et al.:Fetal activity in 100 normal third trimester preg-nancies. Br. J. Obstet. Gynaecol. 87 (1980) 480

[15] SADOVSKY, E., H. YAFFE: Daily movementrecording and fetal prognosis. Obstet. Gynecol. 41(1973)845

[16]'SADOVSKY, E., H. YAFFE, w. z. POLISHUK:Fetal movements monitoring in normal and patho-logic pregnancy. Int. J. Gynecol. Obstet. 12 (1974)75

[17] SADOVSKY, E., W. Z. POLISHUK: Fetal movementsin utero. Obstet. Gynecol. 50 (1976) 49

[18] SADOVSKY,E., Z.WO*LFE, w.z. POLISHUK et al.:Fetal movements recorder, use and indications. Int.J. Gynecol. Obstet. 15 (1977) 20

[19] SCHMIDT, W., H. J. HENDRIK, L. GAROFF et al.:Significance of fetal body movements in early andin late pregnancy as assessed by real-time ultrasound.Eur. J. Obstet. Gynaecol. Reprod. Biol. 1984 (sub-mitted for publication)

[20] THOMSON, A. M., W. Z. BILLIEWICZ, F. E. HYT-f EN: The assessment of fetal growth. Br. J. Obstet.Gynaecol. 75(1968)903

[21] TIMOR-TRITSCH, J.,I. ZADOR, R.H.HERTZ etal.:Classification of human fetal movement. Am. J.Obstet. Gynecol. 126 (1976) 70

[22] WENDERLEIN, J. M.: Erleben der Fetalbewegungen.Z. Geburtsh. Perinat. 179 (1975) 377

[23] WOOD, C., W. A. W. WALTERS, P.TRIGG: Methodsof recording fetal movement. Br. J. Obstet. Gyne-col. 84 (1977) 561

Received October 10, 1983. Revised December 28, 1983. j jAccepted March 3, 19 84. !i

Priv. Doz. Dr. med. W. Schmidt .Universitäts-FrauenklinikVoßstraße 96900 Heidelberg, F. R. Germany

Present address:Yale UniversityDept Ob/Gyn, School of Medicine333 Cedar StreetNew Haven, Connecticut 06510USA

J. Perinat. Med. 12(1984)

j. perinat. med. maternal perception of fetal movements

Documents